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• STATE OF CALIFORNIA • a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH F ILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT []KS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ d AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION b ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME - NAME OF OPERATOR <br /> rY�Y! <br /> ADDRESS / NEAREST CROSS STREET PARCEL A(OPTIONAL- <br /> S, SYz c2 c s/cc acs <br /> CITYNAME STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> v Box s /v c/ctiL CA <br /> q S�U c 1 O - 5/& I/- -/, <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY#GENCY <br /> DISTRICTSQ STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.#(gNrona1) <br /> 0 RESERVATION <br /> O 3 FARM Q d PROCESSOR S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) _ PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I /t Y/LE G:n 2�;x IG Y—YJd L <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHHREA COOE NNSHTS: NAME(LAST,FIRST) <br /> PHONE J!UjjH AREA COOP <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES9 (•� ✓ boa birml# Q INDIVIDUAL Q LOCAL.AGENCY Q STATE AGENCY <br /> v G?� G/iL/(� SI Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITU NAME STATE ZIP CODE l PHONE#WITH AREA CODE r <br /> 21 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 0IvIcab Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITN AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 p 3 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ haab Wkau Q 1 SELFINSURED 1�2 GUARANTEE 0 3 INSURANCE <br /> Q S LETTEROFCREDQ 99 OTHER <br /> T Q 6 EXEMPTION Q d SURE BONG <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA NTED B SIGNATURE( APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# fv. I C 1 .-T 2 Z <br /> LO � � � as17 <br /> CATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 'SUPVISOR-DISTRICT CODE -OPTIONAL <br /> L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE Of SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> /^�/ FOROMA•S <br />